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Background Pre-operative myocardial fibrosis and remodeling impact on outcomes after aortic valve replacement (AVR). We aimed at investigating the prognostic impact of preoperative electrocardiographic (ECG) markers of left ventricular (LV) myocardial damage, i.e. bundle branch block (BBB) and ECG strain pattern after (surgical or transcatheter) AVR for severe aortic stenosis (AS). Methods Between April 2008 and October 2017, we explored consecutive patients referred to our Heart Valve Clinic for first AVR for severe AS. Detailed pre-operative phenotyping and ECG analysis were performed. Patients were followed-up after AVR for major cardiac events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. Results BBB and ECG strain were respectively observed in 13.5 and 21% of the 1122 patients included. These ECG markers identified a subgroup of older patients, with higher NYHA class and more advanced myocardial disease as detected by echocardiography, i.e. higher LV mass and lower LV ejection fraction, global longitudinal strain and integrated backscatter, than patients without ECG strain or BBB. ME occurred in 212 (18.6%) patients during a mean follow-up of 4.4 ± 1.5 years with higher incidence in case of ECG strain or BBB (HR 1.56, 95%CI 1.13–2.14, p = 0.006; HR 1.47, 95%CI 1.02–2.13, p = 0.04 respectively). The prognostic value of ECG strain remained significant after adjustment for age, diabetes and pre-operative LVEF. Conclusions Pre-operative ECG markers of myocardial damage identify a subgroup of AS patients at high risk of post-AVR cardiovascular complications irrespective of other prognostic factors and should help the multiparametric staging of cardiac damage to guide AVR.

BACKGROUND After an emergent surgery for type A acute aortic syndrome, medical management is based on optimal blood pressure (BP) control. We assessed the prognostic significance of BP monitoring and its relationship with aortic morphology following type A acute aortic syndrome. METHODS The data of 120 patients who underwent BP monitoring after a type A acute aortic syndrome from January 2005 to June 2016 were retrospectively collected. The first CT angiogram performed after surgery was used for the morphological analysis. RESULTS The population included 79 males, with an overall mean age of 60 ± 12 years. Seven patients (5.8%) died during a median follow-up of 5.5 years. The median delay between BP monitoring and discharge was 3 (1-5) months. The mean 24-hour BP of the cohort was 127/73 mm Hg ± 10/17. During follow-up, different parameters of BP monitoring were not associated with the risk of aortic events. However, the diameter of the false lumen of the descending thoracic aorta was the best predictor associated with the risk of new aortic events during follow-up, particularly for the threshold of 28 mm or more (P

For decades, numerous observations have shown an intimate relationship between von Willebrand factor (VWF) multimer profile and heart valve diseases (HVD). The current knowledge of the unique biophysical properties of VWF helps us to understand the longstanding observations concerning the bleeding complications in patients with severe HVD. Not only does the analysis of the VWF multimer profile provide an excellent evaluation of HVD severity, it is also a strong predictor of clinical events. Also of importance, VWF responds within minutes to any significant change in hemodynamic valve status, making it an accurate marker of the quality of surgical and transcatheter therapeutic interventions. The authors provide in this review a practical, comprehensive, and evidence-based framework of the concept of VWF as a biomarker in HVD, advocating for its implementation into the clinical decision-making process besides usual clinical and imaging evaluation. They also delineate critical knowledge gaps and research priorities to definitely validate this concept.

Minimally invasive cardiac surgery is mainly dedicated to acquired left-sided valve diseases. Ministernotomy is widely used for aortic valve repair or replacement, whereas pulmonary valve repair via this approach has been reported only recently. This article aims to describe the use of ministernotomy for pulmonary valve replacement in adult congenital patients.

Valve-sparing aortic root replacement with the David procedure is an alternative to the Bentall procedure in patients with aortic root aneurysm. The aim of this study was to describe our long-term experience with this technique and the predictive factors of late failure.Between January 1998 and August 2019, 300 consecutive patients underwent a David procedure. Clinical and echocardiographic early- and long-term outcomes were analyzed. Median follow-up was 7.0 years (range, 4.1-11.5), with 98.3% complete.Early mortality was 1%. No early valve-related reoperations occurred. There were 9 cardiac-related deaths and 22 reinterventions (19 valve-related). All patients survived reoperation. In 3 patients reintervention consisted of transcatheter aortic valve implantation. Overall survival rates were 95.3% (95% confidence interval [CI], 92.0-97.2), 91.1% (95% CI, 86.5-94.2), and 82.9% (95% CI, 75.3-88.4) at 5, 10, and 15 years, respectively. Freedom from postoperative aortic insufficiency (AI) grade ≥ 2 was 84.8% (95% CI, 79.9-88.6) and 74.3% (95% CI, 67.4-79.9) at 5 and 10 years, respectively. Freedom from reintervention for aortic valve disease was 97.1% (95% CI, 94.2-98.5), 92.9% (95% CI, 88.2-95.7), and 92.5% (95% CI, 87.1-95.7) at 5, 10, and 15 years, respectively. Preoperative AI ≥ 2 (hazard ratio, 1.782; 95% CI, 1.352-2.350) and a ventriculoaortic junction ≥ 29 mm (hazard ratio, 3.379; 95% CI, 1.726-6.616) were predictive factors for postoperative AI ≥ 2 in a multivariate analysis (P.001).Preoperative AI ≥ 2 and a ventriculoaortic junction ≥ 29 mm were identified as risk factors for late postoperative AI ≥ 2.

BackgroundDuring peripheral extracorporeal veno-arterial membrane oxygenation (VA-ECMO) support, subclavian arterial cannulation provides, in comparison to femoral arterial cannulation, an anterograde flow which may prevent from left ventricular (LV) distention and improve outcomes. We aimed to compare the effectiveness of subclavian cannulation to femoral cannulation in reducing LV overdistension consequences, hemostatic complications and mortality.MethodsThis retrospective study conducted in two intensive care units of the Lille academic hospitals from January 2013 to December 2019 included 372 non-moribund adult patients supported by VA-ECMO. The primary endpoint was a new onset of pulmonary edema (PO) or LV unloading. Secondary endpoints were myocardial recovery, serious bleeding (according to Extracorporeal Life Support Organization definition), thrombotic complications (a composite of stroke, cannulated limb or mesenteric ischemia, intracardiac or aortic-root thrombosis) and 28 day mortality. Differences in outcomes were analyzed using propensity score matching (PSM) and inverse probability of treatment weighting adjustment (IPTW).ResultsAs compared to femoral cannulation (n = 320 patients), subclavian cannulation (n = 52 patients) did not reduce the occurrence of new onset of PO or LV unloading after PSM [HR 0.99 (95% CI 0.51–1.91)]. There was no other difference in outcomes in PSM cohort. In IPTW adjustment cohort, subclavian cannulation was associated with reduced recovery and increased serious bleeding with four accidental decannulations observed.ConclusionSubclavian artery cannulation was not associated with reduced LV distension related complications, thrombotic complications and 28 day mortality. Rather, it may increase serious bleeding and accidental decannulations, and reduce recovery. Therefore, subclavian cannulation should be limited to vascular accessibility issues.

International audience; BACKGROUND: Although recommendations encourage daily moderate activities in post aortic dissection, very little data exists regarding cardiopulmonary exercise testing (CPET) to personalize those patient's physical rehabilitation and assess their cardiovascular prognosis.METHODS: We aimed at testing the prognostic insight of CPET regarding aortic and cardiovascular events by exploring a prospective cohort of patients followed-up after acute aortic dissection.METHODS: Patients referred to our department after an acute (type A or B) aortic dissection were prospectively included in a cohort between September 2012 and October 2017. CPET was performed once optimal blood pressure control was obtained. Clinical follow-up was done after CPET for new aortic event and major cardio-vascular events (MCE) not directly related to the aorta.RESULTS: Among the 165 patients who underwent CPET, no adverse event was observed during exercise testing. Peak oxygen pulse was 1.46(1.22-1.84) mlO2/beat, that is, 97 (83-113) % of its predicted value, suggesting cardiac exercise limitation in a population under beta blockers (92% of the population). During a follow-up of 39(20-51) months from CPET, 42 aortic event recurrences and 22 MCE not related to aorta occurred. Low peak oxygen pulse (

Background The best valvular substitute remains controversial in young adults with active aortic valve endocarditis. The Ross procedure has gained interest because of its theoretical resistance to infection. We aimed to report our long-term outcomes of the Ross procedure in this indication. Methods Between March 1992 and January 2019, 511 patients underwent a Ross procedure in our institution. Among them, we included 38 patients who suffered from an active aortic valve infective endocarditis. The mean age was 33.9 ± 8.1 years. Six patients had emergent procedures and 17 patients had perivalvular involvement. A pulmonary autograft was implanted using the full root technique in 78.9% of patients. Median follow-up was 12 (interquartile range, 1.75-16.25) years. Results The hospital mortality rate was 5.3%. Estimated overall survival was 84.2% ± 6.6% at 10 years. There were 2 cases of recurrent endocarditis, both requiring reoperation. Six other patients required reoperation on an autograft or homograft. Estimated freedom from recurrent endocarditis or reoperation was 89.4% ± 5.9% at 10 years. Conclusions In experienced centers, the Ross procedure is a reliable alternative to prosthetic or homograft valve replacement in young adults experiencing active aortic valve endocarditis, with a low operative risk and good long-term results.

International audience; Background: The main risk factor for bleeding in patients with continuous-flow mechanical circulatory support (CF-MCS) is the acquired von Willebrand factor (VWF) defect related to the high shear-stress forces developed by these devices. Although a higher bleeding rate has been reported in CF-MCS recipients who had reduced pulsatility, the relation between pulsatility and the VWF defect has never been studied.Objectives: The purpose of this study was to investigate the relation between pulsatility and VWF under CF-MCS.Methods: We assessed the effect of 2 CF-MCS on VWF multimer degradation in a mock circulatory loop (model 1). Using these devices, we investigated in a dose-effect model (model 2) 3 levels of pulsatility in 3 groups of swine. In a cross-over model (model 3), we studied the effects of sequential changes of pulsatility on VWF. We reported the evolution of VWF multimerization in a patient undergoing serial CF-MCS and/or pulsatile-MCS.Results: We demonstrated the proteolytic degradation of VWF multimers by high shear CF-MCS in a circulatory loop without pulsatility. We observed both in swine models and in a patient that the magnitude of the VWF degradation is modulated by the pulsatility level in the high shear-stress level condition, and that the restoration of pulsatility is a trigger for the endothelial release of VWF.Conclusions: We demonstrated that the VWF defect reflects the balance between degradation induced by the shear stress and the endothelial release of new VWF triggered by the pulsatility. This modulation of VWF levels could explain the relationship between pulsatility and bleeding observed in CF-MCS recipients. Preservation of pulsatility may be a new target to improve clinical outcomes of patients.

International audience; Background - Ventricular arrhythmias (VAs) can occur after continuous flow left ventricular assist device (LVAD) implantation as a single arrhythmic event or as electrical storm (ES) with multiple repetitive VA episodes. Objective - We aimed at analyzing the incidence, predictors, and clinical impact of ES in LVAD recipients. Methods - Patients analyzed were those included in the multicenter ASSIST-ICD observational study. ES was consensually defined as occurrence of ≥3 separate episodes of sustained VAs within a 24-hour interval. Results - Of 652 patients with an LVAD, 61 (9%) presented ES during a median follow-up period of 9.1 (interquartile range [IQR] 2.5-22.1) months. The first ES occurred after 17 (IQR 4.0-56.2) days post LVAD implantation, most of them during the first month after the device implantation (63%). The incidence then tended to decrease during the initial years of follow-up and increased again after the third year post LVAD implantation. History of VAs before LVAD implantation and heart failure duration > 84 months were independent predictors of ES. The occurrence of ES was associated with an increased early mortality since 20 patients (33%) died within the first 2 weeks of ES. Twenty-two patients (36.1%) presented at least 1 recurrence of ES, occurring 43.0 (IQR 8.0-69.0) days after the initial ES. Patients experiencing ES had a significantly lower 1-year survival rate than did those free from ES (log-rank, P = .039). Conclusion - There is a significant incidence of ES in patients with an LVAD. The short-term mortality after ES is high, and one-third of patients will die within 15 days. Whether radiofrequency ablation of arrhythmias improves outcomes would require further studies.

Purpose The CorWave LVAD employs a unique “wave membrane” technology, inspired from the motion of aquatic animals, to generate blood flow. This low shear method of blood propulsion can be rapidly modulated to produce a physiologic pulse. The present study evaluated the hydraulic, hemodynamic and hemocompatibility performance of the device in vitro and in animal implants. Methods The pump membrane, oscillation frequency and magnitude, and blood flow path were simulated by CFD analysis in COMSOL and refined to improve hydraulic efficiency and eliminate areas of flow stagnation. Hydraulic testing in a mock circulatory loop and hemolysis measurements in static and pulsatile conditions were then performed in vitro. Acute and chronic implants of the improved pumps were carried out in sheep. Results The device was successfully operated in 4 different modes: continuous or fixed (similar to rotary VADs with a constant operating point), synchronous co-pulsation and counter-pulsation, and asynchronous pulsation modes. Sensorless detection of native ventricle systole was developed using a mock circulatory loop, with performance confirmed in acute implants in sheep with induced heart failure. The pump could generate average flow rates of 6+ lpm against physiologic pressure, and instantaneous flow rates exceeding 12 LPM during pulsatile operation. Acute and chronic animal implants (up to 60+ days) demonstrated low hemolysis and an absence of significant thrombus or thromboembolic events. Conclusion The first long-term chronic animal studies of the CorWave LVAD validated the hemocompatibility and hemodynamic performance of the pump. The ability to restore physiologic pulsatility by sensorless synchronization with the native heart was demonstrated in pre-clinical implants. Extensive computational simulation and bench top testing were used to optimize this unique LVAD, displaying the full flow capacity and adding physiologically relevant pulsatility without excessive shear rates.

For decades, numerous observations have shown an intimate relationship between von Willebrand factor (VWF) multimer profile and heart valve diseases (HVD). The current knowledge of the unique biophysical properties of VWF helps us to understand the longstanding observations concerning the bleeding complications in patients with severe HVD. Not only does the analysis of the VWF multimer profile provide an excellent evaluation of HVD severity, it is also a strong predictor of clinical events. Also of importance, VWF responds within minutes to any significant change in hemodynamic valve status, making it an accurate marker of the quality of surgical and transcatheter therapeutic interventions. The authors provide in this review a practical, comprehensive, and evidence-based framework of the concept of VWF as a biomarker in HVD, advocating for its implementation into the clinical decision-making process besides usual clinical and imaging evaluation. They also delineate critical knowledge gaps and research priorities to definitely validate this concept.

Introduction Hemorrhagic complications, especially mucosal bleedings, are very common for using continuous-flow mechanical circulatory supports (CF-MCS) including Extracorporeal Membrane Oxygenation (ECMO). CF-MCS could impact platelets by exposing this key player in primary hemostasis to high shear stress. A proteolytic cleavage (shedding) of platelet adhesion receptors GpIb and GpVI has been described under high shear stress and could contribute to the hemorrhagic complications in patients with CF-MCS. Objective To assess whether CF-MCS promotes GpIb and GpVI shedding in vitro and in vivo and determine the kinetic evolution during the CF-MCS. Method First platelet shedding was investigated in vitro using a CF-MCS (Impella-CP®, Abiomed) loop model. Plasma with normal platelet count (plasma-NPC) was obtained by dilution of platelet-rich plasma collected from healthy donors in fresh frozen plasma. Sampling was performed before and after 2, 5, 30, 60 and 180 min perfusion of plasma-NPC in the loop model (n = 4 runs). Platelet shedding was also investigated for the blood samples collected from 20 ECMO patients (WITECMO-h trial). Platelets of 20 healthy volunteers were evaluated as a control. GpIbα and GpVI shedding was analyzed by flow cytometry. Results A significant time-dependent decrease of GpIbα (P Conclusion CF-MCS induces platelet GpIb and GpVI shedding in vitro. Increased GpIb and GpVI shedding is already present before ECMO implantation and remain significantly elevated after the implantation. Loss of the platelet receptors GPIbα and GPVI in patients with CF-MCS may contribute to hemorrhagic complications observed in these patients.

Background Cerebral microbleeds have been observed in “asymptomatic” elderly patients undergoing systematic MRIs and might be related with cognitive decline. A defect in Von Willebrand factor (VWF) after Trans Aortic-valve Replacement (TAVR) enhanced bleeding risk and possibly contributes to vascular malformations. Aim To define the occurrence of “acute” microbleeds during TAVR and the clinical and procedural factors associated with this occurrence including a post-procedural defect in VWF. Methods A prospective cohort of patients with aortic stenosis referred for TAVR was included. A standardized neurological assessment, a cerebral magnetic resonance imaging (MRI) and a biological analysis including quantification of VWF multimers and PFA-CADP were performed before and after TAVR. Results Eighty-four patients completed the imaging protocol. On pre-procedural MRI, 22 patients (26%, 95%CI = 17–37%) had at least one microbleeds. After TAVR, new microbleeds were observed in 19 (23%, 95%CI = 14–33%) patients. The occurrence of new microbleeds was independent of the presence microbleeds at baseline. A lower HMW-multimer-ratio as measured immediately at the end of the procedure was associated with the occurrence of new microbleed detected on the MRI performed 3 days after the procedure (0.90 ± 0.14 vs. 1.06 ± 0.27, P = 0.009). The same observation was made with a higher CT-ADP (165 ± 72 vs. 127 ± 57, P = 0.02). A prolonged procedure (RR = 1.21 [1.01–1.170] for every 5 min of fluoroscopy time, P = 0.04) and post-procedural acquired-VWF-defect (RR = 1.42 [1.08–1.89] for every lower “0.1 unit” of HMW-multimer-ratio, P = 0.004) were the only factors associated with the occurrence of new post-procedural microbleed(s). Conclusions We report for the first time a high incidence (23%, 95%CI = 14–33%) of new post-procedural cerebral microbleeds occurring during TAVR. Procedural management and persistence of acquired-VWF defect could play a major role in the occurrence of those new microbleeds.

VWF (von Willebrand factor ) is a circulating multimeric blood glycoprotein. VWF plays a major role in primary hemostasis by promoting the adhesion of platelets to subendothelial collagen at sites of vascular damage and thereby promoting platelet aggregation. VWF is synthesized in endothelial cells and megakaryocytes. The VWF units dimerize and are transported into the Golgi apparatus, where disulfide bonds are formed leading to formation of VWF multimers. This large subunit combination is required to support its hemostatic function. VWF has the unique features to be circulating in an inactive coiled form, hiding binding domains for platelet receptors and subendothelial collagen. At the site of vascular injury, VWF binds to the exposed collagen and unfolds. Once VWF is unfolded, the VWF A1 domain is exposed allowing the binding of platelets via GP Ib (glycoprotein IB) receptor. After platelet activation, GP IIb/IIIa (glycoprotein IIb/IIIa) receptor becomes able to bind VWF C1 domain. The VWF conformation and activity is intimately related to shear conditions and blood flow. At high shear rate (beyond 10–15 pN), it becomes unfolded exposing binding sites but also the cleavage site in VWF A2 domain for ADAMTS13 (adisintegrin-like and metalloprotease thrombospondin) protease that conducts to its proteolysis. Overall, these environmental changes generate the modification of the conformation of VWF …

Introduction Major vascular (VAC) and life-threatening or major bleeding (LT/MB) complications represent the most frequent adverse outcomes of percutaneous transfemoral TAVR (TF-TAVR). Point-of-Care Ultrasound (POCUS) guidance allows the opportunity to obtain in real-time valuable anatomic informations to puncture in the ideal non-calcified central and horizontal segment of femoral artery. We sought to evaluate in our study the impact of implementation of POCUS-guidance on the vascular and bleeding complications. Method POCUS-guidance for vascular access was implemented as the default approach in our institution in 06/2013 for all TF-TAVR and was applied by all operators after a short training course. Thus, we defined three period and groups of consecutive patients according to the method of puncture (fluoroscopic or POCUS-guidance) and the generation of THV (2nd or 3rd gen.). TF-TAVR with POCUS-guidance and 2nd generation THV and from 06/2013 to 11/2014 (POCUS-guided-2nd gen. group; n = 119) were 1:1 successfully matched with 95 patients of the Fluo-guided-2nd gen. with propensity-score (10 variables) (The last TF-TAVR with guidance with 2nd gen. THV; n = 119). TF-TAVR implanted with 3rd gen. THV from 11/2014 to 12/2018 (POCUS-guided-3rd gen. group; n = 308) were analyzed separately. Results After propensity-matching, all the vascular and bleeding complications were reduced in the POCUS-guided-2nd gen. group compared to Fluo-guided-2nd gen. group with respectively: VAC (6,3% vs. 16,8%; OR = 0,31; 95% CI = 0,12–0,85; P = 0,023); LT/MB (22,1% vs. 6,3%; OR = 0.24, CI = 0.09-0.63; P = 0,004); and VAC related to vascular access (12,6 vs. 4,2%; OR = 0,31; CI = 0.10–1.01; P = 0,052). Conclusion This is the first and the largest study to demonstrate that POCUS-guided cannulation of the femoral artery is associated with a reduction of vascular and bleeding complication and support POCUS-guidance as the gold-standard for TF-TAVR.

Purpose The aimed of this study was to evaluate the outcome of the patients successfully weaned from ECMO after cardiac recovery. Methods From January 2008 to January 2018, 384 patients were supported with VA ECMO for cardiogenic shock in our institution. 47.1% patients (n=181) died during support. 40.9% patients were weaned from VA-ECMO (n=157), 5.7% (n=22 were supported with a LVAD or a TAH and 6.3%patients (n=4) received a heart transplant. We prospectively followed the patients weaned from ECMO by periodic visit at our center. We analyzed survival, causes of early and late deaths and predictors for death for this population. Results 157 patients, median age 52 years (1st and 3rd quart. 39-62), were successfully weaned from VA ECMO after a median time of 7 days of support (1st and 3rd quart. 4-10 days). Main etiologies of shock were post cardiotomy (n=57, 36.3%), acute myocardial infarction (n=39, 24.8%), pulmonary embolism (n=11, 7.0%), myocarditis (n=6, 3.8%), and acute end stage heart failure (n=6, 3.8%). During a mean follow up of 1.9 years (max 10 years), 137 patients were discharged home. Early deaths ( 2 years from ECMO weaning) were due to septic shock (n=4), heart graft failure (n=1), unknown (n=1). Three patients underwent HTx, 2 others patients are still waiting for a HTx,. Overall one-month, 6- month and 3-years survival were respectively of 93.4 (IC: 87.7-96.5); 83.4% (IC: 75.3- 89.0) and 76.5% (IC: 65.1-84.6). By multivariate Cox analysis, ECMO duration (HR= 1.15, p=0.0002), stroke during ECMO course (HR =3.85, p=0.0015), age (HR=1.06, p=0.0008), and post cardiotomy shock (HR =3.62, p=0.0124) were independent risk factor for death. Conclusion In our ten-year experience, patients could be successfully weaned from ECMO after a refractory shock. Most of them had a satisfactory outcome and could be discharged home. Older age, a longer duration of support, stroke and post cardiotomy shock were associated with poor outcome. Further studies are needed to evaluate the risk of recurrence of heart failure and a close follow up of those patients is mandatory.

Postprocedural aortic regurgitation occurs in 10 to 20% of patients undergoing transcatheter aortic-valve replacement (TAVR) for aortic stenosis. We hypothesized that assessment of defects in high-molecular-weight (HMW) multimers of von Willebrand factor or point-of-care assessment of hemostasis could be used to monitor aortic regurgitation during TAVR.We enrolled 183 patients undergoing TAVR. Patients with aortic regurgitation after the initial implantation, as identified by means of transesophageal echocardiography, underwent additional balloon dilation to correct aortic regurgitation. HMW multimers and the closure time with adenosine diphosphate (CT-ADP), a point-of-care measure of hemostasis, were assessed at baseline and 5 minutes after each step of the procedure. Mortality was evaluated at 1 year. A second cohort (201 patients) was studied to validate the use of CT-ADP in order to identify patients with aortic regurgitation.After the initial implantation, HMW multimers normalized in patients without aortic regurgitation (137 patients). Among the 46 patients with aortic regurgitation, normalization occurred in 20 patients in whom additional balloon dilation was successful but did not occur in the 26 patients with persistent aortic regurgitation. A similar sequence of changes was observed with CT-ADP. A CT-ADP value of more than 180 seconds had sensitivity, specificity, and negative predictive value of 92.3%, 92.4%, and 98.6%, respectively, for aortic regurgitation, with similar results in the validation cohort. Multivariable analyses showed that the values for HMW multimers and CT-ADP at the end of TAVR were each associated with mortality at 1 year.The presence of HMW-multimer defects and a high value for a point-of-care hemostatic test, the CT-ADP, were each predictive of the presence of aortic regurgitation after TAVR and were associated with higher mortality 1 year after the procedure. (Funded by Lille 2 University and others; ClinicalTrials.gov number, NCT02628509.).

We report a case of nosocomial mediastinitis and sternal osteitis due to M. hominis after open-heart surgery in an immuno-competent patient. This infection has been diagnosed by incubating the culture media for an extended period of time, and sequencing 16S rDNA directly from the clinical samples.

Purpose The CorWave LVAD employs a unique “wave membrane” technology, inspired by the motion of aquatic animals, to generate blood flow. This low shear method of blood propulsion can be rapidly modulated to produce a physiologic pulse. CorWave LVADs have been implanted for up to 2 months in sheep with low hemolysis and good hemodynamic performance. We are finalizing the clinical system by confirming system durability, conducting final blood path optimization, and challenging the pump pulsatility control algorithms. Methods Computational simulations were used to optimize shear stress in the blood flow path to less than 9 dyn/cm2, the maximum that occurs in normal physiology. Test fixtures and prototype pumps were employed to confirm the hydraulic and hemocompatibility results with the optimized flow paths. Test pumps were placed in static and dynamic mock circulation loops for real-time testing, initially targeting 6 months, but then extending to indefinite test durations. The pulsatility control algorithms were tested for sensorless synchronization, arrhythmia detection, pulse pressure amplitude generation, in mock circulation loops (MCLs) and during acute implants in sheep with ischemia-induced heart failure. Results In vitro tests of the optimized flow paths confirmed significant improvements in hydraulic output and hemocompatibility measures. Hemolysis was reduced by 70%, while pump output increased by 30%. 7 pumps completed 6-month durability tests, with testing beyond 6 months ongoing in 6 additional pumps. The pulsatility algorithms successfully detected ventricular systole in heart failure models in MCLs and during acute implants, allowing the aortic valve to open with each beat prior to increasing the pump output. The algorithm identified arrhythmia conditions for safe transitions to non-synchronized operating modes. In vitro, CorWave pumps generated pulse pressures exceeding 30 mmHg, while in vivo pulse pressure increased to over 25 mmHg but was constrained due to limitations of the animal model. VWF multimers were preserved during the acute implants. Conclusion The CorWave LVAD has achieved milestones for durability, hemocompatibility, and pulsatile operation, demonstrating substantial progress towards clinical readiness.

International audience; Objectives: Prone positioning and venovenous extracorporeal membrane oxygenation (ECMO) are both useful interventions in acute respiratory distress syndrome (ARDS). Combining the two therapies is feasible and safe, but the effectiveness is not known. Our objective was to evaluate the potential survival benefit of prone positioning in venovenous ECMO patients cannulated for COVID-19-related ARDS.Design: Retrospective analysis of a multicenter cohort.Patients: Patients on venovenous ECMO who tested positive for severe acute respiratory syndrome coronavirus 2 by reverse transcriptase polymerase chain reaction or with a diagnosis on chest CT were eligible.Interventions: None.Measurements and main results: All patients on venovenous ECMO for respiratory failure in whom prone position status while on ECMO and in-hospital mortality were known were included. Of 647 patients in 41 centers, 517 were included. Median age was 55 (47-61), 78% were male and 95% were proned before cannulation. After cannulation, 364 patients (70%) were proned and 153 (30%) remained in the supine position for the whole ECMO run. There were 194 (53%) and 92 (60%) deaths in the prone and the supine groups, respectively. Prone position on ECMO was independently associated with lower in-hospital mortality (odds ratio = 0.49 [0.29-0.84]; p = 0.010). In 153 propensity score-matched pairs, mortality rate was 49.7% in the prone position group versus 60.1% in the supine position group (p = 0.085). Considering only patients alive at decannulation, propensity-matched proned patients had a significantly lower mortality rate (22.4% vs 37.8%; p = 0.029) than nonproned patients.Conclusions: Prone position may be beneficial in patients supported by venovenous ECMO for COVID-19-related ARDS but more data are needed to draw definitive conclusions.

Background Despite expanding use, knowledge on extracorporeal membrane oxygenation support during the COVID-19 pandemic remains limited. The objective was to report characteristics, management, and outcomes of patients receiving extracorporeal membrane oxygenation with a diagnosis of COVID-19 in France and to identify pre-extracorporeal membrane oxygenation factors associated with in-hospital mortality. A hypothesis of similar mortality rates and risk factors for COVID-19 and non–COVID-19 patients on venovenous extracorporeal membrane oxygenation was made. Methods The Extracorporeal Membrane Oxygenation for Respiratory Failure and/or Heart failure related to Severe Acute Respiratory Syndrome-Coronavirus 2 (ECMOSARS) registry included COVID-19 patients supported by extracorporeal membrane oxygenation in France. This study analyzed patients included in this registry up to October 25, 2020, and supported by venovenous extracorporeal membrane oxygenation for respiratory failure with a minimum follow-up of 28 days after cannulation. The primary outcome was in-hospital mortality. Risk factors for in-hospital mortality were analyzed. Results Among 494 extracorporeal membrane oxygenation patients included in the registry, 429 were initially supported by venovenous extracorporeal membrane oxygenation and followed for at least 28 days. The median (interquartile range) age was 54 yr (46 to 60 yr), and 338 of 429 (79%) were men. Management before extracorporeal membrane oxygenation cannulation included prone positioning for 411 of 429 (96%), neuromuscular blockage for 419 of 427 (98%), and NO for 161 of 401 (40%). A total of 192 of 429 (45%) patients were cannulated by a mobile extracorporeal membrane oxygenation unit. In-hospital mortality was 219 of 429 (51%), with a median follow-up of 49 days (33 to 70 days). Among pre-extracorporeal membrane oxygenation modifiable exposure variables, neuromuscular blockage use (hazard ratio, 0.286; 95% CI, 0.101 to 0.81) and duration of ventilation (more than 7 days compared to less than 2 days; hazard ratio, 1.74; 95% CI, 1.07 to 2.83) were independently associated with in-hospital mortality. Both age (per 10-yr increase; hazard ratio, 1.27; 95% CI, 1.07 to 1.50) and total bilirubin at cannulation (6.0 mg/dl or more compared to less than 1.2 mg/dl; hazard ratio, 2.65; 95% CI, 1.09 to 6.5) were confounders significantly associated with in-hospital mortality. Conclusions In-hospital mortality was higher than recently reported, but nearly half of the patients survived. A high proportion of patients were cannulated by a mobile extracorporeal membrane oxygenation unit. Several factors associated with mortality were identified. Venovenous extracorporeal membrane oxygenation support should be considered early within the first week of mechanical ventilation initiation. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New